Interpreting the CDCs Revised Recommendations for HIV Testing of

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					Implementing Routine HIV Testing in Clinical Settings in Massachusetts

Massachusetts Department of Public Health Office of HIV/AIDS June 2009

Table of Contents
Section Section 1: Introduction………………………………………………………………….. Section 2: Informed Consent and Minimum Counseling Requirements………….. Section 3: Maintaining Patient Confidentiality……………………………………….. Section 4: Models for the Implementation of Routine Testing in Clinical Settings Provider-initiated Testing Model………………………………………….. Counselor-initiated Testing Model……………………………………….. In-house Counseling and Testing Program Referral Model…………… Section 5: Connecting Clients to Care………………………………………………... Section 6: Tools and Resources………………………………………………………. Page 3 7 11 13 13 16 19 21 22

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Section 1

Introduction
In September 2006, the Centers for Disease Control and Prevention (CDC) issued the “Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings” in which the CDC recommended the routine testing of all adult and adolescent patients for HIV in the United States. These revised recommendations served to update the previous recommendations published by the CDC in 2001. The 2006 revised recommendations may be accessed on the CDC website at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm. The Massachusetts Department of Public Health (MDPH), Office of HIV/AIDS Bureau (OHA) produced this document to assist health care facilities and clinical settings in the development and implementation of strategies for the routine offering of HIV testing to patients. Health care providers are encouraged to assess their existing clinical environments, patient base and resources to determine a testing model that works best for the facility and patient population before implementing the offering of routine testing. The CDC revised recommendations advocate for routine HIV testing as part of the normal standard of care provided to patients, regardless of the patient’s motivation for seeking services at the health facility or whether the patient presents symptoms of underlying HIV infection. The routine offering of HIV testing aims to identify unsuspected HIV infection in patients seeking care from health care providers. The standard practice of screening for disease or illness may identify unrecognized health conditions prior to the presentation of physical symptoms and allow for treatment and the implementation of interventions to reduce the likelihood of transmission in the case of communicable diseases. From 2005 to 2007 in Massachusetts, 31% of all individuals newly diagnosed with HIV infection acquired an AIDS defining condition within two months (Massachusetts HIV/AIDS Epidemic at a Glance Factsheet, November 2008). The routine offer of HIV testing in clinical settings may identify individuals living with HIV infection who would otherwise not have been tested, decreasing the number of HIV+ patients that are late to care and at risk of AIDS. Early identification of HIV and entry to care may reduce associated mortality, morbidity and transmission of infection to others. Routine offer of HIV testing may also result in fewer missed opportunities for HIV treatment, medical management and positive prevention. The 2006 revised recommendations state that “HIV infection is consistent with all generally accepted criteria that justify screening,” including:  HIV infection is a serious illness that can be diagnosed prior to the

Background

Rationale

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development of symptoms; HIV infection can be detected using reliable, inexpensive and noninvasive tests; HIV positive patients may experience a long and productive life if diagnosed and treated early; Benefits of testing and knowing one’s HIV status are greater than the direct costs of screening.

The recommendation to include HIV testing as a part of routine clinical care is intended for providers in:  Primary care settings  Hospital emergency departments  Urgent care clinics  Inpatient services  Sexually transmitted disease (STD) clinics  Tuberculosis (TB) clinics  Substance abuse treatment programs  Community health centers  Correctional health care facilities The 2006 CDC revised recommendations do not modify the testing guidelines for non-clinical HIV Counseling, Testing and Referral (CTR) settings and programs such as community based organizations, drop-in centers, outreach settings and mobile vans. Key Points To review the CDC’s full recommendations for HIV testing in health care settings, please refer to the 2006 Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. This section will only cover key points of the recommendations and illustrate how these recommendations align with Massachusetts public health legislation and clinical practice. For all health care settings with prevalence of 0.1% or greater of undiagnosed HIV infection in patients, the CDC advises the routine screening for HIV infection of all patients aged 13-64 years. If a health care facility does not have available data to ascertain the prevalence of undiagnosed HIV infection, providers should offer HIV testing until the prevalence is established. If the yield of HIV infection in the patient population is less than one in one thousand, routine screening is not recommended. Routine testing for HIV infection is also recommended for:  all patients initiating treatment for tuberculosis  all patients seeking testing and treatment for STDs  all pregnant women (ideally during the routine panel of prenatal tests and possibly again during the third trimester)

Significant changes described in the 2006 revised recommendations are outlined below in Table 1. Please note that not all recommendations

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made by the CDC may be implemented in Massachusetts under current state law and regulation. Recommendations for providers practicing in Massachusetts are described in the right-hand column of Table 1. Discordant recommendations are in italics.

Table 1

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CDC Revised Recommendations HIV screening is recommended for patients in all heath-care settings after the patient is notified that testing will be performed unless the patient declines (opt-out screening). Persons at high risk for HIV infections should be screened for HIV infection at least annually. Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing. Prevention counseling should not be required with HIV diagnostic testing or as part of HIV screening programs in health-care settings. HIV screening should be included in the routine panel of prenatal screening tests for all pregnant women. HIV screening is recommended after the pregnant woman is notified that testing will be performed unless she declines (opt-out screening). Repeat screening in the third trimester is recommended in certain jurisdictions with elevated rates of HIV infection among pregnant women.

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Massachusetts Recommendations HIV screening is recommended for patients in all heath-care settings after the patient is notified that testing may be performed provided that the patient chooses to test (opt-in screening). Persons at high risk for HIV infection should be screened for HIV at least annually. General consent for medical care is sufficient to encompass consent for HIV testing if there is a distinct section within the general consent that addresses HIV testing as required by M.G.L.c.111, § 70F. Minimum prevention counseling is recommended with HIV diagnostic testing or as part of HIV screening programs in health-care settings. Review of MDPH issued informational materials for the public regarding HIV testing is considered adequate prevention counseling. HIV screening should be included in the routine panel of prenatal screening tests for all pregnant women. HIV screening is recommended after the pregnant woman is notified that testing may be performed provided that she chooses to test (opt-in screening). Repeat screening throughout pregnancy is recommended in certain jurisdictions with elevated rates of HIV infection among pregnant women and as needed based on the individual’s risk.

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Massachusetts General Law (M.G.L), c. 111, § 70F precludes health care providers from testing patients for HIV infection without written informed consent. Therefore, all HIV screening must be “opt-in screening.” To access the written law, please refer to: http://www.mass.gov/legis/laws/mgl/111-70f.htm.

Models for Implementation

This document describes three models for implementing the routine offer of HIV testing in clinical settings. Please note that there are other models that may effectively offer routine HIV testing in a health care setting. Providers are advised to develop and implement a model that best fits their existing clinical framework, resources and patient base. The three models described in further detail on page 12 are:  Provider-initiated testing  Counselor-initiated testing  In-house HIV counseling and testing program referral As mentioned previously, this document is intended to assist health care providers to understand the CDC recommendations for routine HIV testing, how these recommendations intersect with Massachusetts public health practice and law, and how to design the implementation of routine testing in a clinical setting. When considering the implementation of routine screening in clinical settings, health care providers are encouraged to: 1. Assess their current clinical environment and patient flow 2. Ascertain available resources (e.g. staff, rapid HIV testing technology, marketing tools, reimbursement mechanisms) 3. Select a model for the implementation of routine testing 4. Select a strategy for approaching patients regarding HIV testing 5. Select tools to support the marketing and implementation of this initiative

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Section 2

Informed Consent and Minimum Counseling Requirements
All HIV testing in Massachusetts is voluntary. The patient has the right to decide whether or not to be tested for HIV infection. Massachusetts state law prohibits testing without consent. Consent for HIV antibody testing is considered a legal document and must be in writing. A general health care consent form is not sufficient for HIV antibody testing, unless distinct language about HIV testing is included within the general consent.

Informed Consent M.G.L. c. 111, § 70F, precludes health care providers from testing patients for HIV without their written informed consent. All HIV testing in Massachusetts is considered “opt-in screening.” To access the law, please refer to http://www.mass.gov/legis/laws/mgl/111-70f.htm. To consent to testing, the following must be conveyed to the patient: • The general purpose and nature of an HIV antibody test (i.e., the test will identify the presence of HIV antibodies, not the virus itself) • That the patient will voluntarily give a blood or oral fluid sample to be tested • The type of information revealed by an HIV antibody test (i.e., a positive antibody test means that an individual has HIV infection) • The possible reasons why one should or should not choose to be tested for HIV The consent form should be available in the patient’s primary language whenever possible. The provider should offer to read the consent form to all patients and be able to explain the content and purpose of the consent form. A blood or oral fluid sample may not be taken unless a patient has signed such a consent form. It is the provider’s responsibility to assess patient competence to give informed consent for HIV antibody testing. Below are some considerations for specific populations: Assessing Competency to Test  Adolescents: Under M.G.L. c. 112, §12F adolescents may, without parental consent, access testing, diagnosis and treatment for certain diseases that pose a threat to the public health (including HIV infection). It is generally accepted that if an adolescent, 13 years or older, has sought HIV antibody testing without parental consent, that adolescent has the right to keep this information confidential, and any disclosure of this information would require the adolescent’s specific, informed, written consent. Individuals under the influence of alcohol or other drugs: It is

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the provider’s responsibility to assess capacity to give informed consent for HIV testing, including the impact of intoxication on decision-making. Testing counselors/clinicians should follow their individual agency’s policies regarding assessing capacity. Being under the influence does not automatically warrant refusal of an HIV test or disclosure of a test result to the patient. Some patients are more coherent and able to give reasoned consent while under the influence of alcohol and other substances, compared to times when they may be undergoing withdrawal. Providers should use their agency policy and personal discretion when assessing capacity to test relating to intoxication.  Developmentally delayed adults or adults with a mental illness: It is the provider’s responsibility to assess capacity to give informed consent for HIV testing, including the impact of mental illness on decision-making. Testing counselors/clinicians should follow their individual agency’s policies regarding assessing capacity. Having a mental illness or being developmentally delayed does not automatically warrant refusal of an HIV test. Providers may use their agency policy and personal discretion when assessing capacity to test relating to mental illness. Questions to consider when assessing capacity: o Does the patient understand the general purpose and nature of an HIV antibody test (i.e., the test will identify the presence of HIV antibodies, not the virus itself)? o Does the patient understand s/he will voluntarily give a blood or oral fluid sample to be tested for HIV antibodies? o Does the patient understand the type of information revealed by an HIV antibody test (i.e., a positive antibody test means that an individual has HIV)? o Does the patient understand the risks and benefits of taking an HIV test?

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Counseling Given the time constraints in offering HIV testing in clinical settings, the Recommendations CDC revised recommendations advise the shortening of HIV counseling and risk assessment sessions. The recommendations state that “prevention counseling should not be required with HIV diagnostic testing or as part of HIV screening programs in health care settings.” The Massachusetts Department of Public Health recommends that, in addition to assessing the patient’s readiness and capacity to test, the following be explained to patients prior to obtaining a specimen for HIV testing:  The purpose of the test and voluntary nature of the procedure  The seroconversion period  Confidentiality of test results  What the test results may mean  What will happen if the test result is positive and how the patient may be linked to HIV treatment and care Many of these components are covered in MDPH’s revised counseling & testing brochure. Reviewing the brochure and addressing patient concerns about the material should fulfill the counseling recommendations set forth by MDPH. Providers must determine the patients’ understanding of the test and the patients’ capacity to provide informed consent. Copies of this brochure may be ordered from the Massachusetts Health Promotion Clearinghouse at http://www.maclearinghouse.com/.

Please refer to Table 2 below, which describes the minimum post-test counseling components to be covered with patients once they receive their HIV test results. Table 2 For HIV Negative Results  Explanation of test results  Assessment of need for social and ancillary services  Make referrals as needed  Prevention education For HIV Positive Results  Explanation of test results  Referral to primary care within 24 hours  Engagement in primary care within one week of receiving positive HIV diagnosis  Assessment of need for social and ancillary services  Make referrals as needed

Please note: If providers or clinicians are not able to refer a patient with a positive HIV test result to primary care within one working business day and ensure engagement into care within a week of the positive diagnosis, the routine offering of HIV testing should not be implemented at that particular health care facility. To ensure patients receive high standards of HIV testing and care, patients should be able to access HIV specialty

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or primary care within seven days to be fully informed of the consequences of infection on their health, their treatment options; and discuss HIV-related concerns with a physician or medical manager. Please refer to Section 5 for more information on connection to care.

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Section 3

Maintaining Patient Confidentiality
As with all clinical and public health activities, strict protection of patient confidentiality must be maintained for all persons offered and receiving HIV services, including HIV counseling and testing. All providers must be familiar with their agencies’ policies regarding confidentiality. Confidentiality policies should be posted visibly and be available to patients upon request.

Maintaining Confidentiality

As described in the previous section, all counselors and clinicians must perform their duties in accordance with M.G.L. c. 111, §70F, which requires a physician, health care provider, or health care facility to obtain written informed consent prior to:  Testing a person for HIV antibodies  Revealing to a third party that a person had an HIV test  Disclosing to a third party the results of a person’s HIV test Information shared with a testing counselor or clinician during any visit must be kept confidential. All medical information sharing is subject to federal law (Health Insurance and Portability and Accountability Act; Public Law 104-191). For more information on the HIPAA Privacy Rule, please go to: www.hhs.gov/ocr/hipaa/. In general, the disclosure of medical information is subject to the HIPAA Privacy Rule. 45 CFR Parts 160, 164. However, since M.G.L. c. 111, § 70 F is more protective of individual privacy than HIPAA, it is not preempted by HIPAA, and providers are required to follow its requirements prior to disclosing information about the results of an HIV test. Although a general release of information may be utilized, there must be a distinct section for releasing HIV testing information Consent for release of information on HIV testing or infection status may only be obtained after a patient has been tested for HIV antibodies and has been informed of his or her status. A patient may not be required to sign an information release form prior to, or as a condition of, obtaining an HIV antibody test. ► Agency Considerations: All agencies should have written policies relating to HIV confidentiality, informed consent for testing and release of HIV-related information. These policies should be reviewed with all agency staff, including the consequences of a staff member’s failure to comply with these policies. Policies should also be available to patients upon patient request. ► Provider Considerations: Testing counselors/clinicians are expected

Release of Information

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to understand and comply with Massachusetts General Laws and all agency-specific policies regarding HIV confidentiality, informed consent for testing, and release of HIV-related information. Testing counselors/clinicians should be able to articulate information regarding confidentiality and informed consent clearly and simply to clients and answer questions clients have regarding these topics. Providers and agencies that have additional questions regarding legal considerations should consult with their agency’s legal department.

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Section 4

Models for the Implementation of Routine Testing in Clinical Settings
This section is to assist health providers in their approach to designing the implementation of routine HIV testing in a clinical setting. Before implementing the offering of routine HIV testing, health care providers are encouraged to: 1. Assess their current clinical environment, patient population and patient flow; 2. Ascertain available resources (e.g. staff, rapid HIV testing technology, marketing tools, reimbursement mechanisms); 3. Select a model for the implementation of routine testing; 4. Select a strategy on how to approach patients regarding HIV testing; 5. Select tools to support the marketing and implementation of this initiative. The three models described in this section are:  Provider-initiated testing  Counselor-initiated testing  In-house counseling & testing program referral Please note: there are numerous alternative models that may be employed effectively within a given facility and clinical environment. These three models are broadly described to elicit thought and conversation as to which strategy best suits the clinical setting in question. In all models, it is preferred that rapid HIV testing and phlebotomy are available. Models may be modified based on available resources and specific clinical settings. For example, if funding and/or staffing for the routine testing of all patients within a clinical setting during all hours of operation is not available or feasible, then an implementation model may be modified so that patients are prioritized based on the presentation of symptoms and disclosed risk indicators for HIV acquisition. Therefore, patients that present with symptoms of infection (e.g. fever or rash) or with a history of high risk behavior that may place them at risk for HIV infection (e.g. injection drug use, unprotected sex) may be pre-screened and offered an HIV test. Alternatively, a health care provider may elect to routinely screen all patients seen during certain hours or on certain days.

ProviderInitiated Testing Model

In this model, the health care provider routinely offers patients an HIV test and recommends testing as a standard component of medical care. There are many variations of this model given available staffing and resources. The term “health care provider” is used broadly in this model and may include individuals such as the patient’s physician, nurse

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practitioner, physicians assistant, intake nurse, medical assistant, phlebotomist/laboratorian and clinic receptionist. This model may use a team approach to introduce and provide the HIV test. For instance, the receptionist may greet the patient and ask the patient to consider HIV testing during the visit while handing over a brochure about HIV testing. In a confidential space, the intake nurse may discuss testing options with the patient while taking vitals, answer questions about HIV testing, and obtain informed written consent. The nurse may obtain the specimen for rapid HIV testing or inform the physician to order an HIV test through the clinic laboratory. Or, the physician may be the individual to walk the patient through testing options, obtain consent and manage the process for procuring a specimen to be tested. The individual to obtain the specimen to be tested may depend on the staff, time and HIV test technology (rapid test versus conventional test) available. Test results should be delivered in person by the physician. In the case of a reactive rapid test or positive conventional test result, physicians (or a clinical provider designated by the physician) should ensure that the patient receives the test result and an explanation of the results of the test and is referred to care for his/her HIV infection. Please see Section 5 for more information on connecting patients to care. Development of the testing model should consider how to:  Maintain patient confidentiality  Provide the patient with the MDPH HIV Counseling & Testing brochure  Assess patient’s capacity to understand the test  Obtain informed written consent to test  Implement pre-test counseling components  Perform the test (rapid HIV test preferred when possible)  Deliver the test result in person  Establish post-test counseling components for positive and negative results  Link to medical, preventive and supportive services as needed (referral within one working business day for patients testing positive for HIV)

As the graphic below illustrates, the provider-initiated testing model may look different depending on the resources available. This model differs from the other two described because it is the health care provider that:  offers the patient an HIV test  reviews testing information and counseling messages with the patient  obtains the informed written consent  arranges specimen procurement The graphic below illustrates a possible model of provider-initiated routine screening.

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Graphic 1: ProviderInitiated Model

Patient walks into clinical setting

Receptionist/intake nurse greets and hands over testing brochure. Testing information may also be posted in the waiting area.

Intake nurse or physician reviews HIV literature with patient and answers any questions about testing process.

Intake nurse or physician obtains Informed written consent

Specimen is obtained for testing by nurse, physician or laboratorian.

Test is performed and results are shared with the patient in person by the patient’s physician.

Patient is linked into medical, preventive and supportive services as appropriate.

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CounselorInitiated Testing Model

In this model, a dedicated HIV counselor routinely offers patients an HIV test and recommends testing as a standard component of medical care during the patient’s clinical visit. Again, there are variations of this model depending on the clinical space and environment. For instance, a dedicated HIV counselor would be available at the clinic to routinely screen patients (days and hours may vary). Brochures and posters advertising HIV testing and hours of availability could be posted in the waiting room. The clinic counselor might choose to approach patients as they wait for their appointment, let them know HIV testing is available and offer to test. If it is preferred that clients in the waiting room not be approached by testing counselors, physicians could ask patients if they are interested in testing and refer the patient to the dedicated clinic counselor after the visit. Counselors should discuss and make arrangements with the clinical staff to determine the appropriate time to conduct the HIV counseling and testing session with the patients (pre or post clinical visit). If the patient decides to be tested, a counselor can escort the patient to a confidential space or exam room to conduct the counseling and testing session. This model differs from the provider-initiated model because it is a dedicated HIV counselor that:  offers the patient an HIV test  reviews testing information with and counsels the patient  obtains informed written consent to test  procures a specimen to be tested and conducts the rapid HIV test (if available)*  delivers the test result to the patient in person  shares the test results with the patient’s physician so the patient may be connected to care as needed. * The availability of rapid HIV testing will facilitate the flow of this model as preliminary results may be delivered to the patient the same day as the test. If rapid HIV testing is not available, a counselor with phlebotomy training may procure the specimen to be tested. The patient should be referred to the clinic laboratory for a blood draw if the counselor is not trained in phlebotomy. When the test result is available, the physician should deliver the test result to the patient and engage him/her into HIV care and support services as needed. Whenever conducting rapid testing, the test results should be delivered in person by the dedicated counselor and should be shared with the patient’s physician. In the case of a reactive rapid test result, the HIV counselor should ensure the patient receives the test result and an explanation of the test result. The counselor should relay the information to the physician who should arrange for confirmatory testing and referral of the patient into care for his or her HIV infection. Please see Section 5 for more information on connecting patients to care.

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Development of the testing model should consider how to:  Maintain patient confidentiality  Provide the patient with the MDPH HIV Counseling & Testing brochure  Assess patient’s capacity to understand the test  Obtain informed written consent to test  Implement pre-test counseling components  Perform the test (rapid HIV test preferred when possible)  Deliver the test result in person  Establish post-test counseling components for positive and negative results  Link to medical, preventive and supportive services as needed (referral within one working business day for patients testing positive for HIV)

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Graphic 2: CounselorInitiated Testing Model

The graphic below illustrates a possible model of counselor-initiated routine HIV testing when the counselor approaches patients in the waiting room.

Patient walks into clinical setting and sits in waiting area for appointment

Patient is approached by the HIV counselor in the waiting room and is handed HIV testing information and consent form

Patient considers testing for HIV and accepts or declines to test

Patient is directed to a confidential space to meet with the HIV counselor before or after the clinical visit as time and patient flow allows

Informed consent is obtained, counseling and HIV testing occurs

If rapid HIV testing occurs, results are immediately shared with the patient in person by the counselor. Physician is notified. If conventional testing occurs, a follow up appointment is made with the counselor. Physician is notified of the test result.

Patient is linked into medical, preventive and supportive services as appropriate

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In-House HIV Program Referral Model

In this model, the patient’s health care provider routinely offers patients a referral to an existing in-house or onsite HIV counseling and testing program for testing services. The clinical facility may have access to an HIV counseling and testing program within the center, and once the collaborative relationship is formalized between the clinical setting and the HIV testing program, counselors from the existing in-house HIV testing program would conduct the counseling and testing process. The physician in the clinical setting would routinely offer HIV testing to all patients and then refer patients that accept testing to the in-house HIV program. In this model, the counselor from the in-house HIV testing program must assume the following components in the counseling and testing session:  Maintain patient confidentiality  Provide the patient with the MDPH HIV Counseling & Testing brochure  Assess patient’s capacity to understand the test  Obtain informed written consent to test  Implement pre-test counseling components  Perform the test (rapid HIV test preferred when possible)  Deliver the test result in person  Establish post-test counseling components for positive and negative results  Link to medical, preventive and supportive services as needed (referral within one working business day for patients testing positive for HIV) *The availability of rapid HIV testing will facilitate the flow of this model as preliminary results may be delivered to the patient the same day as the test. If rapid HIV testing is not available, a counselor with phlebotomy training may obtain a serum or oral fluid specimen to be tested (via blood draw or oral mucosal transudate (OMT)). When test results are made available to the counselor and physician, the counselor or the patient’s physician may deliver the test result to the patient and engage him/her into HIV care and support services as needed. When initially discussing this collaborative arrangement, the clinical practice and HIV testing program should decide who delivers the result to the patient- the testing counselor or the patient’s physician.

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Graphic 3: Referral to Testing Model

The graphic below illustrates this model of referring to an in-house HIV Counseling and Testing program.

Patient walks into clinical setting

HIV testing information is shared with the patient by the physician

Patient considers testing for HIV and accepts or declines to test

Post clinical visit, physician calls internal HIV testing program. Counselor meets patient in the clinic and brings patient to a confidential space.

Informed consent is obtained, counseling and HIV testing occurs

Results are shared with the patient in person by the counselor. Physician is notified.

Patient is linked into medical, preventive and supportive services as appropriate

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Section 5

Connecting Clients to Care
Following the delivery of a confirmed positive HIV test result, it is imperative that patients are linked to medical care in a timely manner. Appointments with a primary care or infectious disease specialist (physician or nurse practitioner) should be scheduled to occur within one week of a patient receiving the HIV diagnosis. Prompt entry into medical care ensures that patients receive appropriate laboratory tests and disease staging. Twenty nine percent of persons testing positive for HIV infection in Massachusetts also receive an AIDS diagnosis with two months; this is referred to as concurrent diagnosis. Individuals testing positive for HIV infection may present with a range of immune suppression and HIV-related symptoms upon diagnosis. In all cases, prompt assessment of health status at baseline is essential to maximize health care outcomes for newly diagnosed individuals. A prompt connection to care also ensures that patients receive complete and accurate information about HIV disease progression, antiretroviral treatment options, management of co-morbid conditions, and guidance to reduce the risks of HIV transmission to sexual and drug injection partners. Connecting HIV-positive patients to medical care also serves as a point of entry for other health, assessment, and social services programs; including: case management, benefits advocacy, substance use treatment, mental health counseling, risk reduction services, and partner services, among others. Linkage to HIV primary care also provides a bridge to connect patients with supported referrals to a range of specialty medical care services, including sexually transmitted infection (STI) treatment, viral hepatitis services, nutrition support, family planning, psychiatry, endocrinology, cardiology, and other areas that may directly impact persons living with HIV/AIDS. There are a number of HIV specialist physicians and practices across the Commonwealth of Massachusetts. For more information on how to support patients receiving a positive HIV test result, please consult MDPH’s “Now that you know: A Guide to Living with HIV”. This tool may be accessed on the Massachusetts Health Promotion Clearinghouse website at http://www.maclearinghouse.com/CatalogPageFrameSet.htm. For additional information and tools on connecting HIV positive clients to care, please refer to the materials and publications available on the Human Resources and Services Administration website at http://hab.hrsa.gov/publications.htm.

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Section 6

Tools and Resources
As a clinical practice begins to think about the implementation of routine offering of HIV testing within its setting, the following tools or resources may provide additional guidance. Massachusetts Department of Public Health (MDPH): http://www.mass.gov/dph/dphhome.htm MDPH Office of HIV/AIDS: www.mass.gov/dph/aids Office of HIV/AIDS Resource Guide: http://www.mass.gov/Eeohhs2/docs/dph/aids/resources_guide.pdf AIDS Action Committee: Hotline: (800) 235-2331 www.aac.org MA Health Promotion Clearinghouse for HIV testing brochures: http://www.maclearinghouse.com/CatalogPageFrameSet.htm HIV Partner Services Information: http://www.mass.gov/dph/cdc/std/services/hivpn.htm HIV/AIDS Surveillance Program: http://www.mass.gov/dph/cdc/aids/aidsprog.htm HIV Reporting in Massachusetts: www.mass.gov/dph/aids HIV Training Calendar: http://www.mass.gov/Eeohhs2/docs/dph/aids/prov_training_calendar.pdf New England AIDS Education Training Center: http://www.neaetc.org/index.cfm

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